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Possibilities    of     Reducing 

Mortality  at  the  Higher 

Age  Groups 


Read   before   the    Section   on   Vital   Statistics, 

American  Publ,ic  Heai^th  Association, 

Colorado  Springs,  September,  1913 


BY 

LOUIS  I.  DUBLIN,  Ph.D.,  Statistician 

Metropolitan  Life  Insurance  Company,  New  York 

1913 


^  f\  ^3^ 


T)f 


// 


POSSIBILITIES   OF  REDUCING  MORTALITY  AT 
THE  HIGHER  AGE  GROUPS. 

Particular  interest  has  been  concentrated,  during  the  last 
decade,  on  the  mortality  at  the  higher  age  groups.  The  unfavor- 
able changes  which  have  been  observ^ed  in  the  death-rates  at  these 
ages  are  in  striking  contrast  to  the  conditions  at  the  younger  ages, 
where,  during  the  last  fifty  years,  marked  improvements  have 
occurred  in  both  sexes.  This  contrast  has  occasioned  much 
comment  from  sanitarians,  the  medical  profession,  and  especially 
from  insurance  executives,  who,  as  you  can  well  imderstand,  are 
deeply  concerned  with  the  vast  possibihties  of  checking  losses 
from  premature  mortality.  The  interest  of  the  community, 
however,  is  paramount  to  all  others  in  view  of  the  great  value  to 
it  of  each  adult,  not  only  in  economic  terms,  but  also  in  the  larger 
social  aspects  which  are  involved  in  the  serious  disturbances  to 
family  life  resulting  from  the  death  of  a  parent  or  a  wage  earner. 

A  ver}^  significant  contribution  to  the  discussion  of  the  subject 
is  the  report  of  Dr.  Irving  Fisher  of  the  Committee  of  One  Hundred 
on  National  Health.  In  this  report.  Doctor  Fisher  pointed  out 
that  the  causes  of  death  which  predominate  at  the  higher  age 
groups  were  preventable  to  a  degree,  and  that,  if  the  diseases  and 
conditions  involved  were  controlled  to  the  extent  of  the  facilities 
of  modem  medicine  and  sanitary  science,  there  would  be  added 
to  the  expectation  of  life  at  least  one  and  one-half  years  at  age  45 . 
This  judgment  of  Doctor  Fisher  is  extremely  conser\^ative  in  view 
of  the  fact  that  his  estimates  did  not  include  the  possible  saving 
from  tuberculosis,  which  is  a  considerable  mortahty  factor  at  the 
older  ages,  and  also  because  he  assigned  no  coefficient  of  pre- 
ventability  to  the  various  forms  of  cancer,  which,  since  his  writing, 
have  shown  a  large  measure  of  possible  control. 

It  is  impossible  at  this  time  to  estimate  in  years  and  days 
with  any  degree  of  precision  what  saving  in  middle  Hfe  can  be 
accomplished.  But  it  is  increasingly-  evident  to  competent 
obser\'ers  that  the  attitude  taken  by  Doctor  Fisher  was  more 
than  justified  and  that  the  possibilities  for  human  conservation 
at  the  present  time  are  much  more  hopeful  than  they  seemed 
five  years  ago.  It  is  the  purpose  of  this  paper  to  consider  some 
of  the  elements  which  enter  into  the  mortality  saving  in  the  higher 

1 


age  groups  and  to  show  what  the  possibiHties  are  for  the  control 
of  the  conditions  which  determine  these  rates. 

Mortality  Changes  in  Ten  Years 

I  present  herewith  Table  I,  which  gives  the  death-rates  for 
males  and  females  for  the  years  1900  and  1911,  respectively,  for 
the  Registration  States  as  they  were  constituted  in  the  year  1900. 
These  included  Connecticut,  District  of  Columbia,  Indiana, 
Maine,  Massachusetts,  Michigan,  New  Hampshire,  New  Jersey, 
New  York,  Rhode  Island  and  Vermont,  which  states  enjoyed 
good  registration  conditions  at  both  dates.  The  figures  presented, 
therefore,  are  quite  comparable  for  the  two  periods.  Figures 
earlier  than  those  for  1900  would  be  most  desirable  for  comparison, 
but  they  cannot  be  obtained. 

TABLE  I 

CoMPARisox   OF  Mortality    of    Males   and   Females    by   Age    Groups. 

Death-rates  per  1,000  Poplxation 

(Registration  States  as  constituted  in  1900) 


Males 

Females 

Age 

Per  Cent. 

Per  Cent. 

1900 

1911 

Increase 
or  Decrease 

1900 

1911 

Increase 
or  Decrease 

Under  5 

54.2 

39.8 

—26.57 

45.8 

33.3 

—27.29 

5-9 

4.7 

3.4 

—27.66 

4.6 

3.  1 

—32.61 

10-14 

2.9 

2.4 

—  17.24 

3.  1 

2.  1 

—32.26 

15-19 

4.9 

3.7 

—24.49 

4.8 

3.3 

—31.25 

20-24 

7.0 

5.3 

—24.29 

6.7 

4.7 

—29.85 

25-34 

8.3 

6.7 

—  19.28 

8.2 

6.0 

—26.83 

35-44 

10.8 

10.4 

—  3.70 

9.8 

8.3 

—15.31 

45-54 

15.8 

16.  1 

-K    1.90 

14.2 

12.9 

—  9.15 

55-64 

28.9 

30.9 

+   6.92 

25.8 

26.0 

+  0.78 

65-74 

59.6 

61.6 

+   3.36 

53.8 

55.  1 

+   2.42 

75  and  over  .  . . 

146.  1 

147.4 

+      .89 

139.5 

139.2 

—  0.22 

All  Ages 

17.6 

15.8 

—  10.23 

16.5 

14.0 

—  15.15 

You  will  observe  that,  for  the  males,  all  age  groups  up  to  and 
including  35^4  show  decreases  in  the  mortalit}^  rates  for  1911 
in  comparison  with  those  for  1900,  the  percentages  of  decrease 
ranging  from  27.66,  for  the  age  group  5-9,  to  3.70,  at  the  age  group 
35^44.  From  this  age  group  onward,  the  rates  for  1911  are 
persistently  higher  than  for  the  earlier  date,  the  largest  difference 
being  at  age  period  55-64,  when  the  percentage  of  increase  reaches 
6.92.     For  females,  the  decreases  in  the  mortality  rates  extend 


up  to  the  period  45-54,  inclusive,  the  decreases  varying  from 
32.61  per  cent.,  at  the  age  group  5-9,  to  9.15  per  cent.,  at  the  age 
group  45-54.  The  ages  55-74  show  a  slight  increase,  and  above 
75  the  rates  for  the  two  periods  are  virtually  identical.  It  is 
evident,  therefore,  that  at  all  ages  the  mortality  has  been  much 
more  favorable  for  the  females  than  for  the  males,  but,  in  both 
sexes,  the  various  forces  which  have  been  at  work  to  reduce  mor- 
talitv  suddenly  lose  their  effectiveness  during  the  period  of 
middle  life,  at  which  time  an  actual  deterioration  occurs.  Above 
age  7  5,  no  significant  changes  have  taken  place  and  we  are  not 
much  concerned  with  a  problem  of  "old  age"  mortality. 

The  Increased  Frequency  of  Certain  Causes  of  Death 

It  is  necessar)^  therefore,  in  our  analysis  to  concentrate  atten- 
tion on  the  diseases  and  conditions  which  cause  the  larger  part 
of  the  mortality  at  the  advanced  ages.  These  include  cancer, 
diabetes,  apoplex}^,  organic  heart  disease,  diseases  of  the  arteries, 
cirrhosis  of  the  liver  and  Bright's  disease.  The  least  median  age 
at  death  of  this  group  is  about  55  years.  Together,  they  form 
51.2  per  cent,  of  all  deaths  at  age  40  and  over,  in  the  Industrial 
mortality  experience  of  the  Metropolitan  Life  Insurance  Company 
during  1911.  The  corresponding  percentage  in  the  Registration 
Area  is  51.4. 

Table  II  shows  the  rate  per  100,000  for  each  one  of  these 
causes  for  the  years  1900  and  1910,  respectively,  in  the  Regis- 
tration States  as  constituted  in  1900. 


Causes    of 


TABLE  II 
Death-rate     per     100,000     of    Population    for     Certain 
Death — Male  and  Female  Combined 
(Registration  States  as  constituted  in  1900) 


Cause  of  Death 

1900 

1910 

Per  Cent. 
Increase 

1 .  Cancer  (all  formsj 

2.  Diabetes 

3.  Cerebral   hemorrhage   and 

apoplexy 

4.  Organic  diseases  of  the  heart 

5.  Diseases  of  arteries 

6.  Cirrhosis  of  liver 

7.  Bright's  disease 

63.5 
11.0 

72.5 

116.0 

5.2 

12.6 

81.0 

82.9 
17.6 

86.  1 
161.6 

25.8 
14.4 
95.7 

30.6 
60.0 

18.8 

39.3      ^ 
396.2  v/ 
M4.3 
[18.  1 

Total 

361.8 

484.  1 

33  8 

It  is  evident  from  this  array  that  the  rate  per  100,000  has 
increased  considerably  in  all  of  the  causes  mentioned,  the  rate 
for  the  seven  diseases  combined  being  33.8  per  cent,  higher  for 
1910  than  for  1900.  The  largest  increases  are  to  be  observed 
for  the  circulatory  diseases,  namely,  the  diseases  of  the  arteries 
and  organic  heart  disease,  the  former  having  increased  close  to 
fourfold  in  the  ten  years.  Similar  conditions  have  been  noted 
by  registration  officials  throughout  this  country  and  in  foreign 
lands,  and  it  may  safely  be  said  that  the  increased  frequency  in 
the  degenerative  diseases  pointed  out  above  represents  a  distinct 
tendency  in  modem  life  which  is  worthy  of  the  most  searching 
attention. 

\A'e  will  now  proceed  to  discuss  the  factors  which,  we  believe, 
are  in  a  large  measure  responsible  for  the  conditions  obser\^ed. 
In  general,  it  is  clear  that  we  must  look  to  the  conditions  of  life 
in  the  earlier  ages  for  an  explanation.  The  organism  at  fifty  is 
little  more  than  what  the  preceding  years  have  made  it.  The 
hereditary  factor,  or  the  so-called  physical  endowment  of  birth, 
must,  to  be  sure,  be  considered;  but,  at  this  advanced  age,  its 
importance  is  largely  overshadowed  by  direct  influences  of  environ- 
ment which  have  continuously  modified  the  ph3^sique.  We  shall 
consider  this  early  environmental  influence  under  three  heads, 
namely : 

(a)  The  occurrence  of  disease  in  childhood  and  early  adult 
life. 

(b)  Habits  and  modes  of  life,  including  especially  such  as 
constitute  what  insurance  men  call  the  "moral  hazards,"  and 

(c)  The  effects  of  occupation. 

The  Effect  of  the  Communicable  Diseases  on  Mortality 

In  the  first  place,  such  diseases  as  organic  heart  disease  and 
Bright's  disease,  which  are  exceedingly  prevalent  at  the  advanced 
ages,  are  often  the  sequelae  to  diseases  occurring  previously, 
namely,  the  acute  infections  of  early  life.  I  need  only  refer  here  to 
the  many  cases  where  scarlet  fever,  diphtheria,  acute  articular 
rheumatism  or  typhoid  fever  have  left  the  patient  impaired, 
either  in  the  circulatory  or  in  the  renal  systems.  Medical  litera- 
ture is  replete  with  cases  of  chronic  nephritis  which  have 
followed  in  the  trail  of  scarlet  fever,  and  of  heart  and  vascular 
lesions  which  had  their  origin  in  typhoid  fever  and  acute  articular 
rheumatism.  These  impairments  often  go  unnoticed  until,  under 
the  stress  of  middle  life,  they  terminate  in  one  or  another  of  the 

4 


degenerative  diseases  which  we  have  just  considered.  In  such 
cases,  the  initial  cause  is  usually  not  indicated  on  the  death  certifi- 
cate, and  it  is,  therefore,  not  possible  for  the  statistician  to  evaluate 
the  importance  of  this  factor.  That  it  is  significant,  however, 
will,  I  believe,  remain  unquestioned. 

This  view  of  the  effect  of  the  acute  infections  must  not  be 
confused  with  that  of  other  students  who,  in  their  discussion  of 
the  mortality  conditions  at  the  higher  ages,  have  assumed  that  the 
acute  diseases  serve  as  a  sort  of  filter  for  the  elimination  of  weaklings 
who  would  not  ordinarily  reach  a  ripe  old  age.  These  writers 
have  asserted  that  the  decreased  incidence  of  these  diseases  during 
the  last  two  decades  has  diminished  the  force  of  natural  selection 
against  the  weaker  stock,  and  that,  as  a  result,  the  mortality  at 
the  higher  ages  has  been  correspondingly  increased.  I  believe 
that  the  weight  of  the  emphasis  should  be  placed  at  the  other  end 
of  the  beam.  Whatever  may  be  the  increase  assigned  to  the 
element  which  they  point  out,  the  direct  results  of  the  infections 
that  occur  in  early  life,  and  which  leave  serious  impairments  in 
heart  and  kidney,  must  be  much  more  significant.  We  must, 
therefore,  concentrate  more  and  more  attention  upon  the  elimina- 
tion of  the  communicable  diseases  of  early  life  in  order  to  reduce 
the  mortality  at  the  higher  ages.  In  the  future,  the  rate  from 
such  diseases  as  organic  heart  disease  and  Bright's  disease  will 
serve  as  an  additional  measure  of  the  efficiency  of  present-day 
control  of  the  communicable  diseases  of  childhood  and  youth. 

The  Effect  of  Venereal  Disease  and  Alcohol 

Secondly,  the  habits  and  modes  of  life  have  their  effect  upon 
the  mortality  at  the  later  ages.  Details  of  personal  hygiene, 
such  as  a  rational  diet,  a  reasonable  amount  of  exercise,  regular 
bathing  and  those  subtle  refinements  of  mental  hygiene,  which 
are  designed  to  conser\"e  nerv^ous  force,  are  of  great  significance. 
Most  important,  however,  for  our  discussion,  are  the  effects  of 
the  venereal  diseases  and  of  the  intemperate  use  of  alcoholic 
beverages. 

The  earlier  incidence  of  gonococcus  infection  and  syphilis 
has  a  decided  effect  upon  the  mortality  at  the  later  ages  from 
the  serious  circulatory,  nervous  and  genito-urinary  diseases  which 
they  induce.  In  the  male,  gonorrhea  often  develops  serious 
involvements  of  the  vascular  system,  and  in  the  female  we  observe 
such  complex  pelvic  disturbances  as  are  responsible  in  so  large  a 
degree  for  many  of  the  operations  which  result  in  a  significant 

5 


part  of  the  female  mortality  over  age  45.  Syphilis  affects  the 
nervous  and  circulatory  systems,  ultimately  giving  rise  to  circu- 
latory and  spinal  lesions,  which  terminate  in  conditions  reported 
as  "locomotor  ataxia,"  "cerebral  hemorrhage,"  "paralysis"  and 
the  various  types  of  mental  alienation.  We  have  the  authority 
of  Osier  that  in  nearly  90  per  cent,  of  the  locomotor  ataxia  cases 
we  find  a  syphilitic  personal  history.  There  are  no  similar  figures 
available  for  the  other  degenerative  diseases,  but  syphilis  surely 
plays  a  prominent  part  in  providing  the  initial  changes  which 
terminate  in  the  causes  mentioned.  Health  officers  should, 
therefore,  give  their  active  support  to  all  movements  which  are 
directed  at  the  control  of  the  venereal  infections. 

The  effects  of  the  intemperate  use  of  alcohol  upon  middle  age 
mortality  are  closely  related  to  those  of  the  venereal  diseases; 
indeed,  there  seems  to  be  a  distinct  correlation  between  these 
two  forms  of  indulgence.  The  statistical  analysis  of  the  subject 
is  full  of  difficulties  in  view  of  the  reticence  of  physicians  to  report 
the  facts  of  alcoholism  on  the  death  certificate.  Yet  the  evidence 
is  unmistakable  that  there  is  a  marked  influence  on  middle  and 
old  age  mortality  from  this  cause.  The  title  "Alcoholism 
(Acute  and  Chronic)"  in  the  census  returns  showed,  in  1911,  the 
not  very  significant  rate  of  4.9  per  100,000;  but  this  is  only  a  trace 
of  the  deaths  resulting  from  alcoholism.  No  one  can  estimate 
the  annual  mortality  loss  that  is  hidden  behind  such  returns  as 
"pneumonia,"  "acute  and  chronic  nephritis,"  "cirrhosis  of  the 
liver,"  "organic  heart  disease"  and  "arteriosclerosis,"  all  of 
which  causes  are  now,  as  we  observed,  on  the  increase  in  their 
incidence  at  the  higher  ages.  If  further  evidence  of  the  causal 
relation  between  alcoholism  and  higher  mortality  were  necessary, 
we  should  need  only  to  refer  to  the  body  of  facts  which  have  been 
accumulating  in  insurance  offices  showing  that  total  abstainers 
are  by  far  the  best  risks  and  that  the  mortality  rates  observed  in 
various  occupations  are  significantly  tinged  by  the  degree  of 
exposure  to  alcohol  which  is  characteristic  of  the  occupation. 

We  cannot,  therefore,  observe  without  alarm  the  reports  of 
the  steadily  increasing  consumption  of  alcoholic  beverages  in  the 
United  States  during  the  last  thirty  years,  as  shown  by  the  reports 
of  the  Commissioner  of  Internal  Revenue.  In  the  period  1881-90, 
the  per  capita  consumption  of  liquors  and  wines  was  13.21  gallons, 
whereas  in  1912  the  figure  per  capita  had  risen  to  21.98  gallons, 
an  increase  of  66.4  per  cent,  since  the  earlier  date.  In  this  changed 
condition,  almost  the  sole  contributing  factor  has  been  the  con- 

6 


sumption  of  malt  liquors.  We  are  becoming,  as  a  nation,  too  free 
in  the  use  of  alcohol,  and  it  is  high  time  that  the  lesson  which 
Germany  has  apparently  learnt  and  is  taking  to  heart,  as  is  shown 
by  the  reductions  in  the  consumption  of  alcoholic  beverages 
recently  observed  in  that  country,  were  applied  among  us  before 
further  damage  is  done. 

The  Effect  of  Occupation. 

Third,  and  most  important,  in  our  discussion  of  the  factors 
contributing  to  middle  age  mortality,  are  the  effects  upon  the  body 
of  the  habits  and  conditions  of  work.  This  is  what  we  may  call 
the  occupation  factor.  We  are  all  familiar  with  the  picturesque 
example  of  the  modern  business  man  who  is  supposed  to  work 
at  white  heat  and  under  great  pressure,  and  who,  as  a  result, 
presents  long  before  due  time  the  classic  picture  of  the  broken- 
down  human  machine  suffering  from  the  whole  gamut  of  the 
degenerative  diseases.  The  sanatoria  and  watering  places  of 
Europe  annually  reap  their  harvest  from  this  product  of  American 
commercial  hfe.  But  we  cannot  be  much  concerned  with  this 
small  group  in  our  discussion.  They  do  not  modify  our  death- 
rates  materially,  which  are  determined  rather  by  the  conditions 
of  life  and  work  prevailing  among  the  industrial  classes  of  the 
country.  We  must,  therefore,  turn  to  this  much  larger  group, 
who,  unfortunately,  have  not  received  sufficient  attention  from 
medical  men  in  their  search  for  the  factors  of  occupational  stress. 

The  character  of  American  industry  has  completely  changed 
in  the  last  fifty  years.  Formerly,  most  work  was  conducted  in 
the  manner  of  the  hand  trades;  to-day,  there  is  evident  all  along 
the  line  a  specialization  of  industry  which  brings  together  under 
one  roof  large  numbers  of  workers,  each  one  performing  some 
small  and  distinctive  part  of  the  total  process.  This  condition 
may  be  best  exemplified,  perhaps,  by  the  changes  that  have 
occurred  in  the  manufacture  of  shoes.  Only  a  few  generations 
ago  the  entire  process  of  shoemaking  was  in  the  hands  of  individual 
workmen,  each  one  of  whom  performed  every  operation  in  the 
process  of  making  a  shoe.  To-day,  in  cities  like  Brockton  and 
Lynn,  there  are  immense  establishments  where  shoes  are  made 
entirely  by  machine  processes  directed  by  specialist  workmen 
who  perform,  at  high  speed  and  over  long  hours,  one  or  at  most 
a  few  operations  in  the  production  of  a  shoe.  What  is  true  of 
shoemaking  is  characteristic  of  other  large  industries. 

This  specialization  has  not  been  carried  to  its  present  degree 

7 


of  perfection  without  having  left  its  mark  upon  the  individual 
workman.  He  no  longer  enjoys  the  pleasure  incident  to  the 
performance  of  a  whole  task.  The  unceasing  whirl  of  high- 
speed machiner}^,  the  persistent  noises  of  the  shop  and  the  neces- 
sar}^  nervous  accommodation  to  the  rapid  movements  of  the 
machines  result,  after  long  periods  of  time,  in  distinct  psychoses. 
Our  vital  statistics  are  not  as  yet  sufficiently  refined  to  indicate 
the  precise  effects  of  these  nervous  conditions  upon  the  health 
of  the  worker,  and  we  can,  at  present,  only  speculate  upon  the 
importance  of  this  factor.  There  are,  however,  sufficient  sugges- 
tions from  physiology  and  pathology  that  these  vague  derange- 
ments of  the  nervous  system,  due  to  speeding-up  processes  and 
to  the  general  maladjustment  of  individuals  to  their  work,  may 
result  ultimately  in  distinct  lesions  of  the  heart  and  kidney. 
Many  cases  of  tuberculosis  and  other  serious  affections  of  early 
life  may  be  traced  to  the  lowering  of  normal  vitality  which  follows 
occupational  stress.  It  is  our  contention  that  this  element  also 
plays  a  large  and  hitherto  unsuspected  role  in  the  causation  of 
the  diseases  of  later  life.  I  urge  for  serious  consideration  a  study 
of  this  phase  of  occupational  hygiene. 

Apart  from  these  subjective  changes,  which,  we  believe,  have 
occurred  as  a  result  of  the  specialization  of  industry,  we  must 
consider  those  objective  phases  of  occupation  which  are  inseparable 
from  present-day  working  conditions.  The  presence  of  large 
numbers  of  workmen  under  one  roof  brings  about  new  and  distinct 
problems  of  hygiene  in  industry.  The  large  shop  at  once  raises 
the  question  of  the  purity  of  the  air  supply,  its  temperature  and 
humidity,  the  adequacy  of  natural  and  artificial  light,  the  pro- 
vision of  lavatories  and  other  sanitary  facilities,  together  with  a 
host  of  minor  details  which  in  their  entirety  markedly  affect  the 
health  condition  of  the  individual  workman.  The  effects  of  high 
temperatures  and  humidity  upon  the  health  and  longevity  of  work- 
people are  best  illustrated  by  the  disheartening  conditions  revealed 
by  Perry  in  his  monograph  on  the  cotton-mill  operatives.  The 
extreme  variations  in  temperature,  as  observed  in  the  steel  mills, 
have  long  been  known  for  their  disastrous  effects  upon  the  work- 
men engaged  therein,  especially  with  regard  to  the  high  incidences 
of  rheumatism  and  pneumonia,  both  of  which  play  a  prominent 
part  in  middle  life  mortality. 

We  must  also  consider  the  factors  of  dusts,  fumes  and  poisons 
which  play  a  significant  part  in  present  day  occupational  mor- 
tality.    The   dusts,  especially  those  of  metallic  or  mineral  origin, 

8 


are  well  known  for  their  effects  upon  the  respiratory  system. 
We  should  remember  in  this  connection  that  many  who  become 
incapacitated  for  continued  work  at  the  dusty  trades  often  enter 
other  and  lighter  work,  dropping  thus  in  the  scale  of  economic 
efficiency,  and  later  succumb  to  other  conditions  of  middle  life. 
The  fumes  and  poisons,  especially  those  which  arise  in  the  refining 
and  handling  of  lead,  copper  and  arsenic,  in  like  manner,  cripple 
thousands  early  in  life,  throwing  them  on  other  industries  for 
indifferent  employment  and  support.  Middle  age  mortality 
returns,  as  they  come  into  our  statistical  laboratory  for  study,  are 
loaded  with  indications  of  occupational  poisonings  of  one  sort  or 
another  in  early  life.  In  no  other  way  can  we  explain  the  large 
incidence  of  the  degenerative  diseases  in  those  cases  of  apparently 
negative  occupations  at  death,  which  on  further  inquiry  reveal 
the  previous  employment  in  trades  like  that  of  the  painter,  com- 
positor, or  laborer  in  paint,  rubber  and  color  works. 

Measures  of  Control 

This  high  mortality  of  middle  life  is  thus  largely  a  resultant  of 
our  occupational  conditions.  What  measures  may  we  then  employ 
in  our  attempts  at  relief?  Essentially  our  future  endeavors  will, 
we  believe,  take  the  following  directions : 

1 .  The  further  development  of  that  type  of  efficiency  engineer- 
ing which  will  result  not  alone  in  economies  of  production,  but  in 
such  economies  of  human  effort  as  will  conserve  the  health 
and  life  of  the  individual  workman.  The  first  viewpoint  is  that 
of  the  industry,  while  the  second  is  essentially  that  of  society  as  a 
whole.  This  programme  will  take  into  account  the  radical  improve- 
ment of  the  conditions  of  work  such  as  the  hours  of  labor,  the 
sufficiency  of  light,  the  purity  of  air,  and  the  maintenance  of  a 
favorable  temperature  and  humidity  in  the  shop.  This  will 
involve  the  enactment  and  enforcement  of  far-sighted  labor 
legislation.  vSuch  efforts  will  amply  repay  employers  and  the 
state  for  the  additional  expense  involved  in  increased  product, 
on  the  one  hand,  and  in  the  extension  of  the  span  of  life,  on  the 
other. 

2.  The  medical  examination  of  workmen,  both  at  the  time  of 
their  entrance  into  the  industry  and  periodically  thereafter.  A 
medical  examination  will  often  discover  the  presence  of  the  organic 
diseases  which  we  have  been  discussing,  and  will  encourage  the 
early  application  of  remedial  measures.  Many  instances  of  this 
kind  of  enlightened  management  are  already  in  evidence.     The 

9 


North  Company  of  Worcester,  Mass.,  during  the  past  year  has 
instituted  the  physical  examination  of  its  twelve  hundred  em- 
ployees. Persons  suffering  from  physical  defects  are  informed 
of  the  fact  and  are  advised  to  secure  proper  treatment.  In  some 
cases,  where  the  nature  of  the  work  has  tended  to  aggravate  the 
condition,  a  change  of  occupation  is  arranged.  An  extension  of 
this  programme  should  be  recommended  b}^  health  officers  and 
social  workers  to  the  managers  of  industrial  establishments.  In  this 
way  the  community  will  receive  the  benefit  of  a  comparatively 
inexpensive  and  most  effective  measure  for  life  conservation. 

3.  The  education  of  workm^en  and  employers  in  the  essentials 
of  occupational  hygiene.  B}^  means  of  lectures  delivered  in  the 
factory  and  before  trade  organizations,  workmen  can  readily 
receive  instruction  which  will  result  in  the  prevention  of  diseases 
and  accidents.  Pamphlets  should  also  be  widely  distributed. 
Xo  programme  of  conservation  in  industry  can  be  thoroughly 
successful  unless  it  has  the  active  co-operation  of  the  workmen 
themselves. 

4.  The  close  study  of  death  certificates  by  officers  of  the  depart- 
ments of  health  and  labor,  to  discover  whether  proper  preventive 
measures  have  been  taken  to  prevent  the  death  when  it  is  sus- 
pected that  industrial  conditions  are  at  bottom  responsible  for  the 
disease  or  condition  reported.  In  this  way,  we  shall  be  able  to 
determine  what  industries  are  contributing,  abnormally,  deaths 
from  preventable  accidents,  from  poisonings  and  from  other 
important  occupational  causes.  Health  and  labor  officials  should 
determine  in  each  instance  whether  the  labor  laws  have  been  com- 
plied with,  and  see  that  the  guilty  persons  are  prosecuted  for 
violations.  This  programme  is  carried  out  fully  in  Great  Britain 
by  the  medical  officers  of  health  of  each  district. 

Diabetes  and  Cancer 

Two  diseases,  diabetes  and  cancer,  which  play  an  important 
part  in  the  mortality  at  the  higher  ages,  still  remain  for  our  brief 
consideration.  WTiile  the  definitive  causes  of  both  diseases  are 
still  obscure,  considerable  progress  has  been  made  recently  in  our 
therapeutic  control  of  them.  Research  directed  in  the  field  of 
the  chemistry  of  metabolism  has  done  much  toward  checking 
the  course  of  diabetes,  especially  in  early  cases.  We  may  expect 
results  from  the  clearer  realization  that  many  cases  of  the  disease 
have  their  onset  in  the  metabolic  disturbances  which  follow 
tubercular  and  traumatic  conditions.     It  will  be  the  particular 

10 


function  of  the  periodical  medical  examination  of  workers  to 
discover  incipient  cases  of  this  disease,  a  large  number  of  which, 
at  the  outset,  can  readily  be  managed. 

The  cancer  situation  is  much  more  involved.  The  increase 
in  the  mortality  rate  from  cancer  has  been  very  decisive,  but 
there  are  indications  that  the  rate  has  probably  reached  its  high- 
water  mark.  Altogether,  the  outlook  for  its  control  was  never 
brighter  than  at  the  present  time.  Not  only  are  the  recent 
contributions  of  the  research  laboratories  to  the  pathology  and 
etiolog}^  of  cancer  most  encouraging,  but  progress  is  also  reported 
in  the  surgical  and  ray  treatment  of  the  disease.  Great  promise, 
moreover,  is  held  out  by  the  campaign  of  popular  education 
which  is  in  full  swing  on  all  sides.  The  aroused  interest  of  the 
public  and  the  better  and  earlier  diagnoses  by  physicians  will 
lead  to  the  discovery  of  many  cases  in  the  early  stages  and  will 
present  them  for  surgical  treatment.  More  especially  should 
efforts  be  concentrated  upon  the  education  of  women  in  the  prac- 
tice of  consulting  the  physician  or  surgeon  upon  the  merest  sus- 
picion of  the  appearance  of  cancer  of  the  female  genital  organs. 
Even  at  this  time,  most  cases  come  to  the  operating  table  all  too 
late.  It  is  against  the  fatal  policy  of  delay  that  the  efforts  of  most 
public  bodies  interested  in  the  problem  should  be  directed. 

In  conclusion,  we  should  add  a  few  words  of  commendation 
for  the  movements  which  have  recently  developed  for  the  better 
care  of  persons  in  middle  life  afflicted  with  functional  disturbances 
of  the  heart  and  kidney.  The  proper  care  of  these  cases,  with 
reference  to  choice  of  occupation,  will  lead  often  to  the  prolongation 
of  life.  Many  of  those  afflicted  can  participate  without  much 
injtury  to  themselves  in  gainful  occupations  if  properly  directed, 
where  without  such  guidance  they  soon  overtax  their  limited 
energies  and  become  imfit  for  any  work.  It  should  be  kept  in 
mind,  however,  that  such  a  policy,  useful  as  it  undoubtedly  is,  will 
have  ultimately  the  effect  of  increasing  oirr  mortality  at  the  older 
ages.  Such  an  increase  should  not  be  looked  upon  with  any 
apprehension,  since  it  is  quite  normal  and  involves  no  social  loss. 

Summary 

We  may  now  summarize  our  discussion  of  the  factors  which 
enter  into  the  possible  reduction  of  mortality  at  the  middle  ages 
as  follows: 

1.  We  must  place  even  greater  emphasis  upon  the  municipal 
control  of  the  communicable  diseases  of  early  life  in  order  to  reduce 

11 


the  instances  of  heart  and  kidney  impairments  which  often  result 
therefrom. 

2.  We  must  encourage  the  movements  directed  against  the 
spread  of  venereal  disease  as  well  as  against  the  intemperate  use 
of  alcoholic  beverages. 

3.  We  must  further  all  efforts  for  the  improvement  of  adequate 
labor  legislation  and  promote  better  understanding  between 
employers  and  employees.  This  programme  will  include  the 
improvement  of  factory  sanitation,  the  medical  examination  of 
employees  and  the  instruction  of  both  employers  and  employees 
in  industrial  hygiene. 

4.  It  will  be  necessary  to  supplement  labor  legislation  with 
the  careful  examination  of  death  certificates,  to  see  that  in  every 
instance  those  who  are  responsible  for  preventable  deaths  are 
properly  prosecuted. 

5.  Finally,  we  must  heartily  encourage  the  movement  for 
public  education  on  all  topics  connected  with  personal  hygiene, 
that  there  may  be  better  co-operation  between  physicians  and 
their  patients  and  that  there  may  be  no  unnecessary  losses  sus- 
tained through  neglect  of  symptoms  pointing  to  serious  organic 
diseases. 


12 


COLUMBIA  UNIVERSITY 

This  bo.^k  is  due  on  the  date  indicated  below,  or  at  the 
expiration  of  a  definite  period  after  the  date  of  borrowing, 
as  provided  by  the  rules  of  the  Library  or  by  special  ar- 
rangement with  the  Librarian  in  charge. 

DATE  BORROWED 

DATE  DUE 

DATE  BORROWED 

DATE  DUE 

1 

C28!638)M50 

1 

RA.436  D85 

Dublin 
Pnfis-ihil  ities  of  reducing:  mortality 


